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Liver transplant using donors after unexpected cardiac death: novel preservation protocol and acceptance criteria
C Fondevila1, A J Hessheimer, A Ruiz
1Department of Surgery, Institut de Malalties Digestives, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain. cfonde@clinic.ub.es
Insights
Unexpected donors after cardiac death (DCD) can provide viable livers for transplantation. Maintaining these donors with normothermic extracorporeal membrane oxygenation (NECMO) and applying strict criteria improves graft acceptance and post-transplant function.
Area of Science:
- Transplantation immunology
- Organ donation and procurement
- Cardiovascular surgery
Background:
- Donors after cardiac death (DCD) are a crucial source of organs but face challenges due to irreversible cardiac arrest.
- Unexpected cardiac arrest in DCD donors, not related to withdrawal of support, presents unique management scenarios.
Purpose of the Study:
- To describe the liver transplant experience with unexpected DCD donors.
- To evaluate the efficacy of normothermic extracorporeal membrane oxygenation (NECMO) in preserving DCD liver grafts.
- To establish criteria for accepting DCD liver grafts.
Main Methods:
- Utilized NECMO to maintain circulatory support and oxygenation in DCD donors after cardiac arrest.
- Monitored blood parameters and cardiopulmonary bypass (CPB) flow during NECMO.
- Cannulated femoral vessels for CPB and NECMO initiation.
- Transplanted 10 out of 40 potential DCD livers between April 2002 and May 2006.
Main Results:
- Successful transplantation of 10 DCD livers with good post-transplant hepatic function.
- Low graft loss rates: one primary nonfunction (PNF) and one hepatic artery thrombosis.
- Identified key parameters (CPR and NECMO times, transaminases, donor age) influencing graft viability.
Conclusions:
- Unexpected DCD donors can be a valuable source of viable liver grafts.
- NECMO maintenance and strict acceptance criteria are essential for successful DCD liver transplantation.
- Careful donor selection and management can overcome the challenges associated with marginal DCD organs.
Abstract:
Donors after cardiac death (DCD) suffer irreversible cardiac arrest prior to donation. We describe our liver transplant experience with DCD whose cardiac arrest is unexpected, not following the removal of ventilatory support, whom we maintain with normothermic extracorporeal membrane oxygenation (NECMO). A potential donor goes into cardiac arrest outside the hospital and is brought to the hospital under continuous cardiopulmonary resuscitation (CPR). The donor is declared dead and placed on a cardiocompressor. Femoral vessels are cannulated and connected to cardiopulmonary bypass (CPB) to establish NECMO. Blood parameters and CPB pump flow are monitored throughout NECMO, which is continued until cold preservation. From April 2002 to May 2006, 10 of 40 potential DCD livers were transplanted. Only one graft was lost to primary nonfunction (PNF) and another to hepatic artery thrombosis. Posttransplant hepatic function was good. Certain parameters, such as CPR and NECMO times, hepatic transaminases during NECMO, and donor age, determined the viability of DCD liver grafts and were used to establish criteria for their acceptance. Though considered marginal, unexpected DCD can represent an important source of viable livers for transplant if strict acceptance criteria are employed and they are maintained with NECMO prior to recovery.
